CHAPTER
Ronald A. Lehman, Jr.
129
Classification of Thoracic
and Lumbar Fractures
INTRODUCTION
Several spinal trauma classification systems have been proposed
to aid surgeons in identifying patterns of injury; however, a
majority of them do not provide surgeons with enough useful
clinical information. An ideal classification system would not be
based on anecdotal surgeon experience and retrospective
descriptive measures, but rather provide a systematic approach
to treatment while predicting clinical outcomes. Historically,
the classification of thoracolumbar fractures has been based on
the mechanism of injury, but applying this type of classification
does not provide reliable guidance toward treatment and
expected outcome. Bucholz and Gill, more than 20 years ago,
published a critique of the existing thoracolumbar classifica-
tion systems, arguing that the current systems at that time did
not represent the complex mechanisms associated with the
injury nor did they take into account the variable neurologic
injury.3 Several attempts have been made at improving the clas-
sification of thoracolumbar injuries, yet historically there had
been a lack of consensus on the optimal classification sys-
tem.7,14,17,18 This overall lack of consensus likely stemmed from
a variety of factors, of which, the most important being the ease
of clinical application. Generally, surgeons are unwilling to
accept a classification system that burdens the user. In addition,
the anatomy associated with thoracolumbar injuries is very
complex, and previous attempts at simplifying the injury mech-
anism have reduced their clinical utility. Creating a system,
which is complex enough to incorporate the intricate thora-
columbar anatomy yet simple enough to be clinically applica-
tion has thus far evaded surgeons.
DEFINING INSTABILITY
The continuing effort to classify thoracolumbar spinal fractures
reflects the contemporary difficulties encountered in defining
or predicting the stability of these injuries. Presumed spinal
instability following trauma has been traditionally based on an
assessment of routine plain radiographs, computed tomogra-
phy (CT), and magnetic resonance imaging (MRI). These stud-
ies capture only an isolated moment in time, providing a static
perspective of the injury, not necessarily correlating with
dynamic deformation occurring at the time of incident. Nicoll
1390
LWBK836_Ch129_p1390-1398.indd 1390
Jason T. Bessey
Alexander R. Vaccaro
defined spinal stability as the absence of deformity or neuro-
logic deficit increasing over time.1 Similarly, Kelly and Whitesides
called a spine unstable if progressive deformity resulted in
increasing neurologic compromise.11 Perhaps White and
Panjabi devised the most comprehensive definition:
Clinical instability is defined as a loss in the ability of the spine under
physiologic loads to maintain relationships between vertebrae in such
a way that there is neither damage nor subsequent irritation to the
spinal cord or nerve roots. In addition there is no development of
incapacitating deformity or pain due to structural changes.27
The difficulty in defining stability despite many previous
attempts led to establishing different categories of instability
rather than degrees of instability. The Spine Trauma Study
Group, a coalition of international spinal traumatologists dedi-
cated to the study of spinal trauma, has defined these catego-
ries to include the following:
Immediate mechanical stability (suggested by the morphol-
ogy of injury)
Long-term stability (indicated by integrity of the posterior
ligamentous complex [PLC])
Neurologic stability (indicated by the presence or absence of
a deficit)
VALIDITY AND RELIABILITY
One of the main purposes of a classification system is to create
a useable, reproducible system with language common to those
who treat thoracolumbar spinal trauma, thereby promoting
efficient and reliable communication. This requires a reason-
able degree of intraobserver and interobserver reliability, which
have been problematic in previous systems. In the case of a
spinal fracture classification system, it is presumed that the
interaction of various forces with the spinal column creates
some basic repetitive injury patterns. The difficulty lies in the
interaction of innumerable variables that go on to produce a
traumatic lesion. It must also compress available information
into reproducible categories without loss of informational con-
tent (i.e., an algorithmic compression process). Such a process
inevitably leads to two pitfalls: (1) either there is a loss of infor-
mation content in favor of simplicity and thus higher reproduc-
ibility or (2) there is a loss of simplicity and reproducibility in
favor of higher informational content.
8/26/11 2:36:18 PM

Most of the previous classification systems are based on
image pattern recognition. However, this does not necessarily
lead to a better understanding of prognosis. A classification sys-
tem, in its truest form, is only useful if it actually and accurately
predicts outcome more accurately than random chance. A clin-
ically useful spine trauma classification scheme should not only
provide a mental construct or model of a complex biomechani-
cal system, but should also be instructive as to the severity of
injury and possible clinical consequences.
Vaccaro et al have described a novel classification system in
an attempt to accommodate the difficulties in adoption of pre-
vious thoracolumbar classification schemes.22 This system was
based on several principles felt to be important to any classifica-
tion system. First, it was intended to provide a universal lan-
guage that could be used in clinical practice and to allow
researchers to prospectively collect data, analyze it, and report
outcomes in an organized and methodical manner. It was also
designed to allow stratification of severity and guidance toward
prognosis and outcome of any thoracolumbar spinal injury.
In this chapter, we will review the historical development of
thoracolumbar classification systems and offer insight into the
creation of the Thoracolumbar Injury Classification and
Severity Score (TLICS).
HISTORICAL OVERVIEW OF
THORACOLUMBAR CLASSIFICATION
SYSTEMS
Historically, the most commonly used classification systems for
thoracolumbar fractures have been the Denis and Arbeitsge-
meinschaft fr Osteosynthesefragen (AO) classifications. These
classification systems became universally used and accepted
despite a lack of appropriate follow-up or validity testing. Con-
sequently, these systems have not been modified or improved
with further understanding of the natural history of thora-
columbar injuries. Several independent studies have ques-
tioned the reliability and reproducibility of these classification
systems. Blauth et al performed a multicenter study on the
interobserver reliability of the AO classification system with
imaging studies from 14 fractures of the lumbar spine. Plain
radiographs and CT scans were reviewed by 22 institutions with
experience in spinal trauma.1 The mean interobserver agree-
ment for the 14 fractures was 67% when simply using the three
main categories (A, B, C) to classify the spinal injuries. The
interobserver reliability corresponding to this evaluation was
0.33, representing only fair reliability. The reliability decreased
with increasing the number of injury categories. Oner evalu-
ated the Denis and AO systems reproducibility using plain
radiographs, CT, and MRI in 53 patients.19 They found fair
reproducibility ( 0.34) with CT scans using the main AO
fracture categories to describe the injury. Using MRI, reproduc-
ibility increased to moderate levels ( 0.42). There was fur-
ther improvement in the reproducibility with subclassification
of type A injuries. Intraobserver kappa values were moderate.
Compared with the AO classification system, interobserver and
intraobserver agreement was better with the Denis classifica-
tion for the major fracture types (CT, 0.60; MRI, 0.52),
although this decreased for the entire classification system (CT,
0.45; MRI, 0.39). Variance, however, was worse due to
an increased difficulty in subclassifying some injury patterns
into a specific injury category.
LWBK836_Ch129_p1390-1398.indd 1391
Chapter 129 Classification of Thoracic and Lumbar Fractures 1391
The AO classification system, by using complex subclassifica-
tions, preserves the detail and complexity inherent to most
fractures. However, it is this complexity that has prevented its
widespread use and applicability to everyday practice. On the
other end of the spectrum is the Denis classification system,
which has taken a very simplistic approach, making it easily
applicable yet not detailed enough to classify all fractures.
Wood et al evaluated both the Denis and the AO systems and
found that they both had only moderate reliability and repeat-
ability.26 The authors were concerned about the tendency for
even well-trained spine surgeons to classify the same fracture
differently on repeat testing.26
The creation of a new thoracolumbar classification and scor-
ing system, the TLICS, by Vaccaro et al was done so keeping in
mind the previously mentioned limitations of the AO and Denis
classification schemes.22 The TLICS system used three individ-
ual yet related aspects of an injury; morphology, PLC integrity,
and neurologic status. Prior to the TLICS, Vaccaro et al
attempted to score injuries using the Thoracolumbar Injury
Severity Score (TLISS) based on the mechanism of injury.24
However, with follow-up validation surveys to outside spine sur-
geons, it became clear that surgeons would rather describe the
appearance of the injury (morphometry) rather than the sus-
pected injury mechanism. Subsequently, the classification sys-
tem was revised to meet these demands and changed into what
is currently known as the TLICS system.
For any new classification scheme, validation studies,
including intraobserver and interobserver reliability, are a
necessity. Several validation studies have been completed ana-
lyzing the utility of the TLICS and older TLISS system. Vaccaro
et al evaluated 71 injuries among five attending spine sur-
geons and compared the reliability of determining the TLISS
for each patient.21 They found reliability when analyzing intra-
and interobserver variability, which compared favorably to
other thoracolumbar classification systems. In addition, Patel
et al evaluated the time-dependent changes of implementa-
tion of the TLISS system.20 They initially evaluated a series of
consecutive patients using the TLISS classification and scor-
ing system. Seven months later they again evaluated the same
series of patients assessing intraobserver reliability. They
found significant improvements in interobserver reliability
over time suggesting that the TLISS system can be reproduc-
ibly taught and applied in a clinical setting. Harrop et al
reported on the work of 48 spine surgeons who evaluated 56
clinical scenarios (thoracolumbar injuries) and classified
them according to the TLISS system.8 More than 90% of
reviewers agreed with the systems treatment recommenda-
tion. They concluded that the TLISS met acceptable reliabil-
ity but suggested replacing injury mechanism with a descrip-
tion of injury morphology and to better define PLC disruption
to improve system reliability.
FACTORS CRITICAL TO CLINICAL
DECISION MAKING
The basis of the TLICS system focuses on three key features of
a thoracolumbar spinal injury. The first is the morphology of
the injury as determined using available imaging studies. The
second is the integrity of the PLC. The final key feature is the
patients neurologic function. Subgroups are used within each
8/26/11 2:36:19 PM
 1392 Section XII Trauma
category to better identify and categorize the injuries. A scoring
system is then used to determine the severity of injury and assist
in injury management.
INJURY SEVERITY SCORE
A scoring system is assigned to each of the three categorical
features, defined as the Injury Severity Score (ISS) and is used
to guide fracture management. For each category, one to three
or four points are assigned representing the severity of the
injury with one being the least severe and four being the most.
An increasing point value represents increased instability and
the likelihood the patient may benefit from surgical interven-
tion. If there are multiple levels injured, then only the highest
scored level is used as the ISS.
MORPHOLOGY: FRACTURE PATTERN
Fracture patterns are divided into three morphologic descrip-
tors: (1) compression, (2) translation/rotation, and (3) distrac-
tion. This is determined by reviewing all available imaging
studies, including plain radiographs, CT, and MRI.
Compression
Axial spinal loading results in a compression deformity with
two distinct fracture patterns. The least severe is isolated buck-
ling of the anterior vertebral body wall (compression fracture).
The more significant injury is the burst fracture, which involves
failure of the posterior cortex of the vertebral body associated
with varying degrees of fragment retropulsion. Points are
assigned to this morphologic injury based on the degree of ver-
tebral body disruption with a compression fracture given
1 point and a burst component given 2 points.22
Rotation/Translation
The rotational or translational morphologic descriptor is used
when spinal column failure is due to torsional or shear forces.
The greatest range of motion within the thoracolumbar spine
is in flexion and extension with the discoligamentous complex
and facets oriented to resist axial rotation and translational
forces. Therefore, failure in rotation or translation requires sig-
nificantly more force and usually results in considerably more
instability than compressive failure.13 Clues for a rotational pat-
tern on plain radiography include horizontal separation of the
spinous processes or disruption of pedicle alignment compared
with adjacent levels on an anteroposterior (AP) plain radio-
graphic image. Currently, with the routine use of CT scans and
their reconstructive software, this fracture pattern can be easily
identified compared with the time periods when previous clas-
sification systems were developed. For translational injuries, a
shift in the midline across the injury site can be seen on con-
secutive axial images. Sagittal reconstructions provide further
information and may be necessary to accurately identify dislo-
cated facets representing a translational injury. As discussed,
these injuries are the result of greater forces and more instabil-
ity than compressive patterns and are therefore assigned
3 points for fracture morphology. The term dislocation can be
interchanged for translation/rotation if the facet joint(s) are
intact but dislocated.
LWBK836_Ch129_p1390-1398.indd 1392
Distraction
The distraction fracture pattern is the result of severe forces
causing discontinuity of the spinal column. Distraction forces
can result in disruption of the ligamentous and bony ele-
ments both anteriorly and posteriorly. The key to applying
this morphologic descriptor is the ability to recognize the
lack of continuity between the cephalad components and the
caudal components at the level of injury. With the forces
required to cause such disruption, the spinal column is very
unstable. In addition, angulation within the sagittal or coro-
nal plane is common at the fracture site. Again, the distrac-
tion descriptor can be combined with the previously
mentioned morphologic descriptors as needed to describe a
complex pattern. Because of the instability associated with
the forces required to create a distraction pattern, these frac-
tures are assigned 4 points.
It is important to remember that any one of the morphologic
descriptors can be combined with another to describe a complex
fracture pattern. For example, with a severe flexiondistraction
injury, there may be an associated compressive and translational
pattern. If this is the case, the fracture would be best described as
a distraction translational compression injury.
In summary, the following points are assigned for morphol-
ogy: compression fracture1 point (1 for burst fracture 2
points); translational/rotational3 points; distraction4
points. If a combined morphology is determined, then the high-
est scoring morphologic descriptor score is used. For example,
in a classic flexion distraction injury in which there is evidence
of compression anteriorly and distraction posteriorly, the
morphologic score would be 4 based solely on the distraction
component.
INTEGRITY OF THE POSTERIOR
LIGAMENTOUS COMPLEX
Components of the PLC include the supraspinous ligament,
interspinous ligament, ligamentum flavum, and the facet joint
capsules, which protect against flexion, rotation, translation,
and distraction. One of the primary roles of the PLC is as a
posterior tension band serving to restrict tension forces between
the posterior elements of the spinal column. Because of its liga-
mentous structure, the PLC does not heal well in the adult
compared with the contiguous osseous structures in the spine,
and therefore, frequently requires surgical intervention. Within
the TLICS system, the integrity of the PLC is categorized as
intact, indeterminate, or disrupted. Again, similar to the mor-
phologic categorization, the use of all available imaging modal-
ities including plain films, CT, and MRI is crucial to an accurate
assessment. In addition, a clinical examination in which there
is palpable ligamentous gap between the spinous processes can
indicate PLC disruption. With a thorough radiologic assess-
ment, splaying of the spinous processes (widening of the inter-
spinous space), diastasis of the facet joints, and facet perch or
subluxation are signs to PLC disruption. Another indirect sign
includes rotation or translation of one vertebral body on
another, which requires disruption of the PLC. In cases in
which the clinical and radiographic assessment fails to deter-
mine the integrity of the ligaments the PLC is labeled as inde-
terminate. If the PLC is intact, 0 points are assigned. If
indeterminate 2 points are assigned, and if disrupted, 3 points
are assigned.
8/26/11 2:36:19 PM

NEUROLOGIC STATUS
Although not included in previous classification systems, neu-
rologic status has long been recognized as an important indica-
tor of the severity of spinal column injury as well as the need
for surgical intervention.16,23. In the TLICS systems, neurologic
status is classified according to the increasing order of surgical
urgency as follows: neurologically intact, nerve root injury,
complete (ASIA A) spinal cord, and incomplete (ASIA B/C/D)
spinal cord or cauda equina injury. Neurologically intact
patients are given 0 points. An associated nerve root injury or a
complete spinal cord injury is assigned 2 points. Patients with
an incomplete spinal cord injury or cauda equina syndrome
are assigned 3 points, representing the surgical urgency associ-
ated with these cases.
Using all three major categories within the TLICS system,
thoracolumbar injuries can be adequately and accurately
described. For example, an injury may be described as a flexion
burst fracture in a neurologically intact patient with a disrupted
PLC.
QUALIFIERS
While the TLICS system attempts to be inclusive and describe
the spectrum of thoracolumbar injuries, it is also designed to
be simple and user friendly to allow for universal usage. In
doing so, it does not include all potential patient variables that
may be used to determine the indications for specific treat-
ment. An individual surgeon may feel that surgery is indicated
when a severe deformity is present regardless of how it scores
or may avoid surgical intervention when doing so is of high risk
to the patient. For example, cases of Diffuse Idiopathic Skeletal
Hyperostosis (DISH), ankylosing spondylitis (AS), and other
metabolic disorders must be given special consideration on an
individual basis when treatment decisions are considered.
Clearly, to incorporate all items that have a role in the treat-
ment decision process would be prohibitive to any classification
system. These qualifiers may sway the final treatment decision
once all morphologic and neurologic factors are considered.22
SCORING SIGNIFICANCE (Fig. 129.1)
A total or comprehensive ISS less than 3 advocates nonopera-
tive treatment and a score greater than 5 would suggest strong
consideration for surgical treatment. Injuries with a score of 4
are difficult to assign into surgical or nonsurgical treatment but
must be considered on an individual basis. This is often modi-
fied by associated qualifiers.
SURGICAL APPROACH
Another advantage of the TLICS system, compared with the pre-
viously mentioned AO and Denis classifications, is potential
insight into a preferred surgical approach if surgical interven-
tion is deemed appropriate. Admittedly, this is a complex topic,
but by placing emphasis on the PLC integrity and the neurologic
status, the TLICS system values two key characteristics in deter-
mining an anterior versus posterior approach. In general, a pos-
terior approach is often favored with disruption of the PLC, and
an anterior approach is often preferred in an incomplete
LWBK836_Ch129_p1390-1398.indd 1393
Chapter 129 Classification of Thoracic and Lumbar Fractures 1393
Identify fracture mechanism
Compression1 point Burst1 point
Assign points Translational/rotation injuries3 points
Distraction injuries4 points
Integrity of posterior ligamentous
complex
No injury0 points
Assign points Indeterminate injury2 points
Definite injury3 points
Neurologic status of patient
Intact0 points
Root injury2 points
Assign points Spinal cord injury (complete)2 points
Spinal cord injury (incomplete)3 points
Cauda equina3 points
Total points determines injury
severity score
Account for any clinical qualifiers
Provide treatment
Figure 129.1. Schematic depicting point assignment based upon
the TLICS classification to determine treatment methods.
neurologic injury with obvious anterior thecal sac compression.
When there is both an incomplete neurologic injury in the set-
ting of anterior thecal sac compression and PLC disruption,
then a combined anterior posterior may be the optimal surgi-
cal approach.25
CONCLUSION
While there are several classification systems in the thoracolum-
bar spine, previously the AO and Denis classification schemes
have been the most popular.1,2,46,913,15,26 The excessive number
of classification systems is related to the inability of one indi-
vidual system to provide reliable and validated results, which
are clinically useful. At the same time, these systems have caused
an unnecessary confusion within the already complex arena of
spine surgery. The new TLICS system appears to provide a rea-
sonable alternative to the many previous attempts at classifying
thoracolumbar injuries.
The TLICS draws from a large breadth of clinical experi-
ence and applies anticipated outcomes to recognized fracture
patterns through its numerical weighting system. It accommo-
dates an injury with a severe morphology, a disrupted PLC, and
a compromised neurologic picture, and translates it to a high-
risk clinical situation most likely requiring surgical interven-
tion. The TLICS has been validated several times to determine
if the scoring system is reliable and reproducible. The result of
this validation process led to modification of the final TLICS
system, which undoubtedly will be modified in the future as our
understanding of thoracolumbar trauma continues to evolve.
Controversy remains in the area of thoracolumbar trauma
diagnosis, treatment, and management. We think that a sim-
pler classification system, which takes into account factors rele-
vant to decision making, is needed. Because this system is based
on carefully chosen, objective clinical indicators linked to
8/26/11 2:36:19 PM
 1394 Section XII Trauma

patient outcome, it should facilitate communication about
injuries and help in making treatment decisions. Finally,
because injury severity is weighted by a point system, the TLICS
system is amenable to modification if factors not yet understood
come to light.
The TLICS describes not only the morphology of thora-
columbar spinal trauma, but also serves to rank the degree of
instability. By including components of neurologic status and
posterior ligamentous integrity, the clinician is forced to con-
sider additional facets of instability and severity. The numerical
scores generated by this process help the treating physician
more appropriately weigh their relative contribution in the
assessment of the spinal injury. As a direct result, the classifica-
tion scheme and ISS can be used to guide clinical management
and surgical approach.

CASE EXAMPLES

CASE STUDY 129.1 Compression Fracture

A 21-year-old male restrained driver injured in a motor
vehicle collision presents without any neurologic symptoms,
but with complaints of back pain. Imaging studies reveal
the presence of an L2 compression fracture (Fig. 129.2).
His injury would be classified as an L2 compression fracture
in a patient who is neurologically intact with an intact PLC.
This injury is assigned 1 point for injury morphology (com-
pression) and 0 points for PLC integrity and neurologic sta-
tus. The total score is 1 point, which supports nonoperative
treatment.

A B

Figure 129.2. (A) Axial. (B) Sagittal.

LWBK836_Ch129_p1390-1398.indd 1394 8/26/11 2:36:19 PM


CASE STUDY 129.2 Burst Fracture with an Intact PLC
A 32-year-old male passenger injured in a motor vehicle col-
lision and presents with symptoms consistent with cauda
equina syndrome and imaging studies consistent with an L3
burst fracture (Fig. 129.3). This injury is classified as an L3
burst fracture in a patient with an intact PLC in the setting
of a cauda equina injury. This patient would be assigned 2
Figure 129.3. (A) Axial. (B) Sagittal.
LWBK836_Ch129_p1390-1398.indd 1395
Chapter 129 Classification of Thoracic and Lumbar Fractures 1395
points for injury morphology (1 for a compressive type
injury and an additional point for the burst component).
The status of the PLC appears to be intact (0 points). Three
points are assigned for a neurologic examination consistent
with cauda equina, giving a total of 5 points. This patient
would be considered a surgical candidate.
B
8/26/11 2:36:20 PM
 1396 Section XII Trauma

CASE STUDY 129.3 Burst Fracture with

Disrupted PLC

A 44-year-old man who fell from a horse presents with

symptoms of severe back pain and is neurologically intact.
Imaging studies are consistent with an L1 burst fracture
(Fig. 129.4). This patient has an L1 burst fracture
(2 points) with a disrupted PLC (3 points) and a normal
neurologic examination for a total of 5 points. He would
be a surgical candidate.

A B

Figure 129.4. (A) Axial. (B) Sagittal.

LWBK836_Ch129_p1390-1398.indd 1396 8/26/11 2:36:20 PM


CASE STUDY 129.4 Translational Injury with PLC Disruption and Cauda Equina Syndrome
A 19-year-old female passenger injured in a multiple motor
vehicle collision and presents with symptoms consistent with
cauda equina syndrome and imaging studies consistent with
a translational fracture dislocation of T12, L1 (Figs. 129.5A
and B). This patient has a translational injury (3 points)
with disruption of the PLC (3 points) and a cauda equina
Figure 129.5. (A) Axial. (B) Sagittal. (C and D), Postoperative
films.
LWBK836_Ch129_p1390-1398.indd 1397
Chapter 129 Classification of Thoracic and Lumbar Fractures 1397
injury (3 points). She is assigned a point total of 9, and is
deemed to be a surgical candidate. Postoperative AP and
lateral films after reduction and posterior spinal fusion
with segmental pedicle screw instrumentation (Figs.
129.5C and D).
D
8/26/11 2:36:21 PM
 1398 Section XII Trauma

15. McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures.
REFERENCES Spine 1994;19:17411744.
16. Meves R, Avanzi O. Correlation among canal compromise, neurologic deficit, and injury
1. Blauth M, Bastian sL, Knop C, et al. Inter-observer reliability in the classification of tho-
severity in thoracolumbar burst fractures. Spine 2006;31(18):21372141.
raco-lumbar spinal injuries. Orthopaedics 1999;28:662681.
17. Mirza SK, Mirza AJ, Chapman JR, et al. Classifications of thoracic and lumbar fractures:
2. Bhler L. Mechanisms of fracture and dislocation of the spine. In Bhler L (ed). The treat-
rationale and supporting data. JAAOS 2003;10:364377.
ment of fractures, Vol. 1, 5th ed. New York, NY: Grune & Straton, 1956:300329.
18. Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg Br 1949;31:376394.
3. Bucholz RW, Gill K. Classification of injuries to the thoracolumbar spine. Orthop Clin
19. Oner F. Thoracolumbar spine fractures: diagnostic and prognostic parameters [Academic
North Am 1986;17:6773.
Thesis]. Utrecht: University of Utrecht, 1999.
4. Chance GQ. Note on a type of flexion fracture of the spine. Br J Radiol 1948;21:452453.
20. Patel AA, Vaccaro AR, Albert TJ, et al. The adoption of a new classification system: time-
5. Denis F. The three-column spine and its significance in the classification of acute thora-
dependent variation in inter-observer reliability of the Thoracolumbar Injury Severity
columbar spinal injuries. Spine 1983;8:817831.
Score classification system. Spine 2007;32:E105E110.
6. Ferguson RL, Allen BL. A mechanistic classification of thoracolumbar spine fractures. Clin
21. Vaccaro AR, Baron EM, Sanfillipo J, et al. Reliability of novel classification system for tho-
Orthop 1984;189:7788.
racolumbar injuries: the Thoracolumbar Injury Severity Score. Spine 2006;31(11):
7. Gertzbein SD. Spine update: classification of thoracic and lumbar fractures. Spine
S62S69.
1994;19:626628.
22. Vaccaro AR, Lehman RA Jr, Hurlbert RJ, et al. A new classification of thoracolumbar inju-
8. Harrop JS, Vaccaro AR, Hurlbert RJ, et al. Intrarater and interrater reliability and validity
ries: the importance of injury morphology, the integrity of the posterior ligamentous com-
in the assessment of the mechanism of injury and integrity of the posterior ligamentous
plex, and neurologic status. Spine 2005;30(20):23252333.
complex: a novel injury severity scoring system for thoracolumbar injuries. J Neurosurg
23. Vaccaro AR, Nachwalter RS, Klein GR, et al. The significance of thoracolumbar spinal
Spine 2006;4:118122.
canal size in spinal cord injury patients. Spine 2001;26:371376.
9. Holdsworth F. Fractures, dislocations, and fracture-dislocations of the spine. J Bone Joint
24. Vaccaro AR, Zeiller SC, Hubert RJ, et al. The Thoracolumbar Injury Severity Score: a pro-
Surg Br 1963;45:620.
posed treatment algorithm. J Spinal Disord Tech 2005;18:209215.
10. Holdsworth F. Fractures, dislocations and fracture-dislocations of the spine. J Bone Joint
25. Verlaan JJ, Diekerhof CH, Buskens E, et al. Surgical treatment of traumatic fractures of the
Surg Am 1970;52:15341551.
thoracic and lumbar spine: a systematic review of the literature on techniques, complica-
11. Kelly RP, Whitesides TE Jr. Treatment of lumbodorsal fracture-dislocations. Ann Surg
tions, and outcome. Spine 2004;29:803814.
1968;167:705717.
26. Watson-Jones R. The results of postural reduction of fractures of the spine. J Bone Joint
12. Louis R. Spinal stability as defined by the three-column spine concept. Anat Clin 1985;7:
Surg Am 1938;20:567586.
3342.
27. White AA, Panjabi MM. Clinical biomechanics of the spine. Philadelphia, PA: Lippincott,
13. Magerl F, Aebi M, Gertzbein SD, et al. A comprehensive classification of thoracic and
1978.
lumbar injuries. Eur Spine J 1994;3:184201.
28. Wood KB, Khanna G, Vaccaro VR, et al. Assessment of two thoracolumbar fracture
14. McAfee PC, Yuan HA, Frederickson BE, et al. The value of computed tomography in tho-
classification systems as used by multiple surgeons. J Bone J Surg Am 2005;87-A(7):
racolumbar fractures: an analysis of one hundred consecutive cases and a new classifica-
14231429.
tion. J Bone Joint Surg Am 1983;65:461473.

LWBK836_Ch129_p1390-1398.indd 1398 8/26/11 2:36:22 PM